Legal Medicine - Articles in Press

Fatal Staphylococcus aureus bacteremia in the Felty syndrome: A maltreatment-suspected case - Corrected Proof

Fumiko Satoh, Yoshihisa Seto, Iwao Hasegawa, Motoki Osawa — 2012-05-07

Abstract: Familial neglect was suspected when an older deceased female was found to have large decubitus ulcers and weight loss. Postmortem examinations including histopathology and bacterial culture revealed systemic Staphylococcus aureus infection as the cause of death. The victim might have exhibited Felty syndrome, which is characterized by complications of splenomegaly and neutropenia in the underlying rheumatoid arthritis. As a result of neutropenia, the affected individual was susceptible to skin ulcer formation and sepsis. The manifestation of pressure ulcers as abuse biomarkers should also be explored from interaction with intrinsic disease factors.

Reply to the letter by Dr. Palmiere and Dr. Mangin - Corrected Proof

Takahito Hayashi, Kazutoshi Ago, Mihoko Ago, Mamoru Ogata — 2012-05-01

In the letter , the authors suggested that diabetic ketoacidosis (DKA) was the direct cause of death and positional asphyxia was a contributing factor in our case , mainly based on the results of postmortem biochemical analyses. We are certain that their opinions should be mostly reasonable. However, we could not determine that the blood levels of ketone bodies such as acetone (204.2μg/ml) and 3-beta-hydroxybutyrate (3HB, 11,844μmol/l) absolutely led to fatal outcome in our case. In addition, we could not exclude the possibility that the polymorphonuclear leukocyte had infiltrated around the subcutaneous hemorrhages in the neck antemortemly. Thus, we judged the phenomenon to be vital reaction of head-down position in our case as described in previous reports of death related to similar positions . Furthermore, the deceased in our case satisfied all criteria for the diagnosis of positional asphyxia and therefore we concluded that the direct cause of death was positional asphyxia, which was due to DKA.

Postmortem ventilation: A new method for improved detection of pulmonary pathologies in forensic imaging - Corrected Proof

2012-04-30

Abstract: Postmortem imaging has gained prominence in the field of forensic pathology. Even with experience in this procedure, difficulties arise in evaluating pathologies of the postmortem lung.The effect of postmortem ventilation with applied pressures of 10, 20, 30 and 40mbar was evaluated in 10 corpses using simultaneous postmortem computed tomography (pmCT) scans. Ventilation was performed via a continuous positive airway pressure mask (n=5), an endotracheal tube (n=4) and a laryngeal mask (n=1) using a portable home care ventilator. The lung volumes were measured and evaluated by a segmentation technique based on reconstructed CT data. The resulting changes to the lungs were analyzed.Postmortem ventilation at 40mbar induced a significant (p<0.05) unfolding of the lungs, with a mean volume increase of 1.32l. Small pathologies of the lung such as scarring and pulmonary nodules as well as emphysema were revealed, while inner livores were reduced. Even though lower ventilation pressures resulted in a significant (p<0.05) volume increase, pathologies were best evaluated when a pressure of 40mbar was applied, due to the greater reduction of the inner livores. With the ventilation-induced expansion of the lungs, a decrease in the heart diameter and gaseous distension of the stomach was recognized.In conclusion, postmortem ventilation is a feasible method for improving evaluation of the lungs and detection of small lung pathologies. This is because of the volume increase in the air-filled portions of the lung and reduced appearance of inner livores.

A new method for quantitative determination of dimemorfan in human plasma using monolithic silica solid-phase extraction tips - Corrected Proof

2012-04-30

Abstract: Dimemorfan was extracted from human plasma samples (100μL) using MonoTip C18 tips, which were packed with a C18-bonded monolithic silica gel attached to the inside of the tip. The samples, which contained dimemorfan and trimeprazine as an internal standard (IS), were mixed with 300μL of distilled water and 50μL of 1M glycine–sodium hydroxide buffer (pH 10). The mixture was extracted onto the C18 phase of the tip by 20 sequential aspirating/dispensing cycles using a manual micropipettor. The analytes retained on the C18 phase were then eluted with methanol by five sequential aspirating/dispensing cycles. The eluate was injected directly into a gas chromatograph and detected by a mass spectrometer with selected ion monitoring in positive electron ionization mode. An Equity-5 fused silica capillary column (30m×0.32mm i.d., film thickness 0.25μm) gave adequate separation of the dimemorfan, IS, and impurities. The recoveries of dimemorfan and the IS spiked into plasma were ⩾83%. The regression equation for dimemorfan showed excellent linearity from 0.25 to 32.0ng/100μL of plasma, and the limit of detection was 0.125ng/100μL of plasma. The maximum intra-day and inter-day relative standard deviations were 13%, while accuracy ranged from 88% to 105%. Dimemorfan was stable for at least 12h at 4°C, 4weeks at −80°C, and three freeze–thaw cycles in plasma. This new method is expected to have application as a pretreatment for the rapid, simple, and quantitative determination of dimemorfan in plasma samples.

Administration of rotenone enhanced voluntary alcohol drinking behavior in C57BL/6J mice - Corrected Proof

2012-04-30

Abstract: Rotenone, a commonly used lipophic pesticide, is a high-affinity mitochondrial complex I inhibitor. The aim of this project is to study the causal relationship between changes of brain monoamine levels and drinking behavior in rotenone-treated mice. In the first experiment, we investigated the effects of acute exposure to rotenone (20mg/kg, p.o.) on the 8-h time limited-access alcohol drinking behavior and brain monoamine levels in C57BL/6J mice at 0, 2, 8 and 24h. Dopamine (DA), 3,4-dihydroxyphenylacetic acid (DOPAC) and 5-hydroxyindoleacetic acid (5HIAA) levels in the nucleus accumbens (ACC), caudate–putamen (C/P) and lateral hypothalamus (LH) of rotenone-treated mice were decreased at 2 and/or 8h. Rotenone-exposed mice showed a suppression of voluntary alcohol intake at 4 and 8h, but total daily alcohol intake did not differ significantly between the two groups. The effects of chronic exposure to rotenone (1, 5, 10 and 20mg/kg, p.o. for 30days) on the alcohol drinking behavior and monoamine levels of rotenone-exposed mice (10mg/kg, p.o.) were investigated in the second experiment. The mice treated with rotenone showed increases in alcohol drinking behavior. Levels of DA and 5-HT in the ACC and C/P of chronic rotenone-treated mice were decreased, while the ratios of DOPAC to DA in the ACC and C/P and of 5HIAA to 5-HT in the ACC, C/P and DRN were increased significantly. Tyrosine hydroxylase immunoreactivity of chronic rotenone-treated mice (10mg/kg, p.o.) slightly were decreased in both the striatum and the substantia nigra. Ethanol and acetaldehyde metabolism was not significantly different between mice treated with rotenone (10mg/kg, p.o.) and controls. It was suggested that rotenone-treated mice had increased alcohol drinking behavior associated with increases in the DA turnover ratios of ACC and striatum to compensate for the neural degeneration.

Diagnosable and non-diagnosable causes of death by postmortem computed tomography: A review of 339 forensic cases - Corrected Proof

2012-04-30

Abstract: Postmortem computed tomography (PMCT) is often used to diagnose causes of death, especially in nations with a low autopsy rate. To identify the causes of death that can and cannot be determined by PMCT, imaging findings were reviewed in 339 consecutive forensic autopsy cases. Causes of death could be determined based on PMCT findings alone in 7% of these cases, based on suggestive PMCT findings with additional information in 54%, and could not be determined by PMCT in 38%. PMCT screening may be useful for establishment of some causes of death, including traumatic intracranial hematoma, endogenous intracranial hemorrhage, and some cases of cardiac rupture. Suggestive findings from PMCT in other cases, such as those involving subarachnoid hemorrhage or pericardial hematoma, can lead to misdiagnosis and may be a pitfall of PMCT screening. Causes of death including some cases of cervical cord injuries, asphyxiation, burn, drug intoxication, acute myocardial infarction, and pulmonary thromboembolism cannot be diagnosed using PMCT.

How to catch child pornographers in France? The entrapment - Corrected Proof

Sebastien Prat, Carol Jonas — 2012-04-30

Child pornography is a form of sexual exploitation of children. The use of telecommunication facilities, particularly the Internet, has allowed child pornography to be distributed more widely. The Internet is used by pedophiles for four reasons: trafficking child pornography; locating a minor for an assault; initiating communication with a minor; and communicating with other pedophiles . Today, access to pedophilic material no longer requires direct contact between supplier and consumer but can be obtained anonymously . It is common for pedophiles and those using child pornography to be part of virtual groups . They can speak freely about their fantasies, their fears, thus maintaining a good image of themselves while obtaining child pornography material. The existence of these virtual groups has become a major issue, as they are not restricted by territorial boundaries.

Suicidal ideation among students of a medical college in Western Nepal: A cross-sectional study - Corrected Proof

2012-04-23

Abstract: Many studies have been conducted in the developed countries to know the magnitude and factors influencing suicidal ideation among medical students, but such data are sparse in developing countries. This cross-sectional study was therefore conducted to find out the prevalence of suicidal ideation and factors influencing such ideation among students of a medical college in Western Nepal. A total of 206 students were selected using random sampling and questioned about their socio-demographic factors, other risk factors and suicidal ideation using a preformed validated questionnaire. The data were analyzed using SPSS for Windows Version 16.0 and the EPI Info 3.5.1 Windows Version. Descriptive statistics and testing of hypothesis were applied for the statistical methodology. The univariate and multivariate logistic regression methods were used to examine the association between different variables. Suicidal ideation in the last one year was present in nearly one tenth of the study population and in almost one fifth of them life-time suicidal ideation was present. Factors that were associated with suicidal ideation were primarily dissatisfaction with academic performance, being in the clinical semesters, having history of drug abuse and feeling neglected by parents. Most common reason reported for suicidal ideation was family related followed by self-related. Recognition of suicidal ideation among students and their associated factors can help in detecting it on time, making the right interventions and controlling the problem. Understanding the magnitude of the problem and their epidemiology via scientific study like this would be the first step in this process.

Estimation of the duration after methamphetamine injection using a pharmacokinetic model in suspects who caused fatal traffic accidents - Corrected Proof

2012-04-16

Abstract: When the population parameters of drug pharmacokinetics in the human body system are known, the time-course of a certain drug in an individual can generally be estimated by pharmacokinetics. In the present two cases where methamphetamine abusers were suspected to have inflicted mortalities in traffic accidents, the time-elapse or duration immediately after methamphetamine injection to the time when the accidents occurred became points of contention. In each case, we estimated the time-course of blood methamphetamine after the self-administration in the suspects using a 2-compartment pharmacokinetic model with known pharmacokinetic parameters from the literatures. If the injected amount can be determined to a certain extent, it is easy to calculate the average time-elapse after injection by referring to reference values. However, there is considerable individual variability in the elimination rate based on genetic polymorphism and a considerably large error range in the estimated time-elapse results. To minimize estimation errors in such cases, we also analyzed genotype of CYP2D6, which influenced methamphetamine metabolism. Estimation based on two time-point blood samples would usefully benefit legal authorities in passing ruling sentences in cases involving similar personalities and circumstances as those involved in the present study.

Difference in molecular pathology of natriuretic peptides in the myocardium between acute asphyxial and cardiac deaths - Corrected Proof

Jian-Hua Chen, Tomomi Michiue, Takaki Ishikawa, Hitoshi Maeda — 2012-04-16

Abstract: In investigating death due to mechanical asphyxiation and drowning, a cardiac attack is important for discriminating between possible causes of death and as a contributory factor in death processes; however, general pathologies involving visceral congestion are often similar. The present study compared terminal cardiac dysfunction in these fatalities using the molecular pathology of atrial and brain natriuretic peptides (ANP and BNP) in the myocardium as markers of cardiac strain. Both mechanical asphyxiation (n=27) and drowning (n=23) showed significantly lower ANP and BNP mRNA expressions in bilateral ventricular walls than sudden cardiac deaths (n=36). In addition, right atrial wall BNP mRNA expression was lower in asphyxiation; however, immunostaining did not demonstrate any difference among these fatalities. Differences among the subtypes of asphyxiation or between fresh- and saltwater drowning were insignificant. These observations suggest a difference between primary heart failure in sudden cardiac death and terminal cardiac dysfunction secondary to fatal asphyxiation or drowning.

Replication study of the association of SNPs in the LHX3-QSOX2 and IGF1 loci with adult height in the Japanese population; wide-ranging comparison of each SNP genotype distribution - Corrected Proof

2012-04-16

Abstract: Adult height is a highly heritable trait involving multiple genes. Recent genome-wide association studies have identified that SNP rs12338076 in the LHX3-QSOX2 locus, and rs1457595 and rs17032362 in the IGF1 locus are associated with human height in the Japanese population (Okada et al. (2010) ). We performed a replication study to examine the associations between these three SNPs and adult height in the Japanese population based on autopsy cases. However, it was not possible to confirm that all these SNPs influenced adult height in the study population. We first conducted a wide-ranging survey of these three SNPs in the above genes using nine different populations including Asians, Africans and Caucasians, and demonstrated that the genotypes of rs12338076 and rs17032362 were distributed in an ethnicity-dependent manner; even within Asian populations, the genotype distributions of the SNPs differed widely. Although there are differences in height distribution between different populations, possibly due to genetic factors and/or gene–environmental interactions, the contradictory results of the association study and ethnic differences in genotype distribution allow us to assume that these height-related SNPs in the genes may contribute to adult height to a slight extent, at least in the Japanese population. It is anticipated that the present information will be useful for developing a reliable tool for personal identification through elucidation of the genetic basis of human height.

Practice of clinical forensic medicine in Sri Lanka: Does it need a new era? - Corrected Proof

Sarathchandra Kodikara — 2012-04-16

Abstract: Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a country. Practice of clinical forensic medicine is evolving, but deviates from one jurisdiction to another. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology. Unlike the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice or training in this discipline. Besides, this is rarely a topic of discussion. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers practice both clinical forensic medicine and forensic pathology. Practice of clinical forensic medicine, and its teaching and training in Sri Lanka depicts unique features. However, this system has not undergone a significant revision for many decades. In this communication, the existing legal framework, current procedure of practice, examination for drunkenness, investigations, structure of referrals, reports, subsequent legal procedures, undergraduate, in-service, and postgraduate training are discussed with suggestions for reforms.

The relationship between adrenal gland morphometric changes and postmortem interval in rats: A stereological study - Corrected Proof

Ayse Kurtulus, Kemalettin Acar, Hulya Sorkun, Canan Kelten, Bora Boz — 2012-04-16

Abstract: The importance of determining time of death is crucial to forensic cases. The ability to use adrenal gland volume changes and adrenal medulla chromaffin cell counts to obtain the postmortem interval was examined in this study.A total of 15 rats were sacrificed by cervical dislocation and divided into three groups. The left adrenal glands were quickly excised in the first group at 0h, in the second group at 12h and in the third group at 24h. Subsequently, the samples were fixed in 10% formalin solution and embedded in paraffin according to standard procedures. Ten to fifteen sections were obtained from each left adrenal gland by taking 30μm thick sections; then, the sections were stained with hematoxylin-eosin (HE). The adrenal cortex and medullar volumes were calculated by Cavalieri’s principle, which is a stereological method. The adrenal medullary chromaffin cell count was evaluated by the optical fractionator method. The total volume of the adrenal gland was determined as 4.82±1mm3 at 0h, 6.32±0.28mm3 at 12h and 8.35±1.73mm3 at 24h. Increases in the adrenal cortex, adrenal medulla and the total volume of the adrenal gland at 12 and 24h postmortem compared with at 0h were statistically significant (p<0.05). The difference between the groups in terms of the total number chromaffin cells was statistically significant (p<0.05).In this preliminary study, we evaluated the total volume of the adrenal gland and the number of chromaffin cells of the adrenal medulla. We concluded that these parameters could be used reliably in determining the postmortem interval.

Identification of nasal blood by real-time RT-PCR - Corrected Proof

Koichi Sakurada, Tomoko Akutsu, Ken Watanabe, Mineo Yoshino — 2012-04-12

Abstract: A new approach for the identification of body fluid stains by comparing specific mRNA expression levels has been extensively studied in recent years. Here, we examine whether nasal blood, which is regarded as one of the most difficult types of blood to identify, can be identified by comparing mRNA expression levels of target genes specific to saliva, nasal secretion, and blood. The saliva-specific statherin gene (STATH) was found to be expressed at high levels in not only saliva (dCt value: 1.32±1.39, n=5), but also nasal secretions (dCt value: 0.90±1.14, n=5), while the histatin gene (HTN3) was only expressed at high levels in saliva (dCt value: 1.08±2.35, n=5). We also confirmed that the hemoglobin-beta gene (HBB) showed high expression levels in blood (dCt value: −9.51±0.40, n=5). Four nasal blood stains were found to highly express STATH (dCt value: 5.65±3.98) and HBB (dCt value: −8.79±1.67) but not HTN3, suggesting that the stain samples contained both nasal secretions and blood and can therefore be identified as nasal blood stains. Although menstrual blood showed the same expression pattern as nasal blood, the menstrual blood-specific protein matrix metallopeptidase 7 (MMP7) was not expressed in all nasal blood stain samples. Therefore, its expression levels could be used to discriminate between nasal and menstrual blood. In conclusion, real-time RT-PCR was able to identify nasal blood, although the stability of gene expression in nasal blood stains was low over time, suggesting that this assay may not be effective for older stains. Future work should examine the usefulness of this assay under various environmental conditions.

University students’ attitudes towards Voluntary Interruption of Pregnancy - Corrected Proof

2012-04-12

Abstract: An evaluation of the future professional trends was performed by analyzing the attitudes of university students to the Voluntary Interruption of Pregnancy (VIP). An anonymous questionnaire was distributed to 300 students (Medicine, Nursing and Law) of the University of Santiago de Compostela, with questions on their personal beliefs, opinion on the law and intention to participate in VIP. Of the 245 respondents (response rate 82%), 66.5% were pro-abortion and their attitudes towards VIP were consistent with their opinion on the beginning of life and with the ethical arguments related to the fetus and the mother. No differences were found with age, sex or degree. The students showed to be well informed on the VIP law, and the majority of them considered unsuitable termination of pregnancy in minors without parental consent. Students’ intentions to take part in abortion provision were influenced by their views on abortion, level of participation and circumstances of pregnancy. Although the majority of participants would be willing to perform VIP in situations that affect fetus and mother’s life or health (87–66%), their intentions clearly diminished in other situations, such as abortion on demand (17%). These data suggest that conscientious objection of health professionals can even increase with the new policy, a fact that might affect VIP availability. It is important to stress the need of ethical training to help in the solution of conflicts between patient and health professional values.

Fatal pediatric head injury due to toppled television: Does the injury pattern overlap with abusive head trauma? - Corrected Proof

Sarathchandra Kodikara, Michael Pollanen — 2012-04-12

Abstract: Pediatric head injuries can occur from abusive head trauma (AHT) or accidents. Accidental pediatric head injuries caused by cathode-ray tube televisions (CRTT) toppling have become a ‘silent epidemic’. Differentiation between a fatal case of AHT and CRTT toppling could be vexing when the historical and scene evidence are subtle.A 2-year-old girl was found unresponsive in her house and could not be resuscitated. A 27” CRTT was found fallen from its stand onto the floor at the scene. The siblings report that the deceased was climbing on the television stand when it toppled. Autopsy revealed a spectrum of head injuries including, contusions, fractures, bilateral acute subdural hemorrhages, subarachnoid hemorrhages, brain contusion–lacerations and corpus callosal hemorrhages. Microscopy of the eyes revealed bilateral acute retinal hemorrhages. The cause of death was given as crushing injuries of head and brain.The skull fracture pattern is compatible with an accident causing crush injury due to the toppled CRTT rather than AHT. The injury pattern reconfirms that the head is the most vulnerable site in case of CRTT tipover. Although there may be an overlap between the injury pattern in AHT and in CRTT tipover cases, a careful evaluation of the history and scene and autopsy findings such as the crushing nature of the skull fractures and distribution of injury, can solve this problem.

A case in which a bone fragment caused by a bullet made a second channel in addition to the bullet channel - Corrected Proof

Marie Bessho, Kana Unuma, Akina Nara, Koichi Uemura — 2012-04-12

Abstract: A 64-year-old male was found dead in his house with his face covered with blood and a 38-caliber revolver between his legs. He had been suffering from type 2 diabetes mellitus and aftereffects of cerebral infarction. Autopsy revealed a normal round contact wound in the left lateral cervical region. A bullet from the firearm had entered through the left lateral cervical region and traveled to the outer right sternocleidomastoid muscle. This also triggered another wound from the fifth cervical vertebra to the muscle tissue near the right cartilage thyroid. At the end of this channel, there were three bone fragments. Here, we report this interesting case with two channels caused by a bullet and by a resulting bone fragment. We also discuss the characteristics of an ear lobe injury found on the victim and show how this injury and blood and skin on the revolver were used as clues to determine the posture at the time of the shot.

Diabetic ketoacidosis or positional asphyxia? - Corrected Proof

Cristian Palmiere, Patrice Mangin — 2012-04-12

We read the article by Hayashi et al. with great interest and would like to commend the authors on their good work. We were also very interested in reading that the authors had initially concluded that the direct cause of death was diabetic ketoacidosis and then changed it to positional asphyxia after having followed the suggestions of other forensic pathologists to reanalyze the features of the case.

Rectal wall hemorrhage in hanging autopsy cases - Corrected Proof

2012-02-27

Abstract: The aim of our study was to analyze hemorrhagic lesions of the rectal wall in hanging autopsy cases. All autopsy reports regarding hanging from January 1st, 2008 to December 31st, 2010 were retrospectively reviewed. One hundred and two hanging cases were selected out of 1379 autopsy cases. Rectal wall hemorrhage was found in about 4% of the cases (n=4). Two of these 4 cases (50%) were associated with bowel wall hemorrhage, suggesting a similar possible etiology by abdominal congestion during the agonal phase. Another etiology could be an hemorrhagic lividity in the rectum. As it is not possible to determine with certainty the etiology, even with the use of histology, the detection of rectal wall hemorrhage cannot be used as another sign of vital hanging. Such rectum changes raise the possibility of sexual assault. Forensic pathologists should be aware of such an occurrence and avoid potential harmful misinterpretation.